{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3563.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3563.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3563.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3563.html"}],"law_id":63745,"edition_id":1,"section_id":63745,"structure_id":14588,"section_number":"38.2-3563","catch_line":"External review of experimental or investigational treatment adverse determinations","history":"2011, c. 788.","full_text":"A\n\nWithin 120 days after the date of receipt of a notice of the right to an external review of an adverse determination or final adverse determination that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, a covered person or his authorized representative may file a request for external review with the Commission.B\n\nA covered person or his authorized representative may make an oral request for an expedited external review of the adverse determination or final adverse determination if the covered person’s treating physician certifies, in writing, that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated. The following shall apply with regard to such requests for an expedited external review:1\n\nUpon receipt of a request for an expedited external review, the Commission shall promptly notify the health carrier;2\n\nUpon notice of the request for expedited external review, the health carrier shall promptly determine whether the request meets the eligibility requirements in subsection D. The health carrier shall promptly notify the Commission and the covered person and his authorized representative, if any, of its eligibility determination. Such notice shall include a statement informing the covered person and his authorized representative, if any, that a health carrier’s ineligibility determination may be appealed to the Commission;3\n\nIf the health carrier makes an ineligibility determination, the Commission may determine that a request is eligible for external review and require that it be referred for external review. The Commission shall make such determination in accordance with the terms of the covered person’s health benefit plan and the requirements of subsection D;4\n\nUpon receipt of the notice that the expedited external review request meets the eligibility requirements, the Commission shall promptly assign an independent review organization to review the expedited request and notify the health carrier of the name of the assigned independent review organization;5\n\nPromptly upon receipt of the notice of the assigned independent review organization, the health carrier or its designee utilization review entity shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination to the assigned independent review organization electronically, by telephone, facsimile, or any other available expeditious method;6\n\nUpon receipt of the notice from the Commission, the assigned independent review organization shall promptly assign one or more clinical reviewers in accordance with the provisions of subdivision F 3 to conduct the external review;7\n\nIn reaching an opinion, each clinical reviewer shall also consider the documents listed in subsection J. Each clinical reviewer shall provide an opinion orally or in writing to the assigned independent review organization as expeditiously as the covered person’s medical condition or circumstances require, but in no event more than five calendar days after being selected. If the opinion provided was not in writing, within 48 hours following the date of the opinion the clinical reviewer shall provide a written opinion to the assigned independent review organization. The written opinion shall include the information described in subsection K. Recommendations from more than one clinical reviewer shall meet the provisions of subsection L; and8\n\nWithin 48 hours after the date it receives an opinion from all clinical reviewers, the assigned independent review organization shall make a decision and provide notice of the decision orally or in writing to the covered person, his authorized representative, if any, the health carrier, and the Commission. If the notice was not in writing, within 48 hours after the date of the notice, the assigned independent review organization shall provide written confirmation of the decision to the covered person, his authorized representative, if any, the health carrier, and the Commission. The decision shall include the information described in subsection M.C\n\nWithin one business day after the date of receipt of the request for a standard external review, the Commission shall notify the health carrier.D\n\nWithin five business days following the date of receipt of such notice, the health carrier shall conduct and complete a preliminary review of the request to determine whether:1\n\nThe individual is or was a covered person in the health benefit plan at the time the health care service or treatment was recommended or requested or, in the case of a retrospective review, was a covered person in the health benefit plan at the time the health care service or treatment was provided;2\n\nThe recommended or requested health care service or treatment is a covered service except for the health carrier’s determination that the service or treatment is experimental or investigational for the particular medical condition and is not explicitly listed as an excluded benefit under the covered person’s health benefit plan;3\n\nThe covered person’s treating physician has certified that one of the following situations is applicable:\n\t\t\t\ta. Standard health care services or treatments have not been effective in improving the condition of the covered person;\n\t\t\t\tb. Standard health care services or treatments are not medically appropriate for the covered person; or\n\t\t\t\tc. There is no available standard health care service or treatment covered that is more beneficial than the recommended or requested health care service or treatment;4\n\nThe covered person’s treating physician:\n\t\t\t\ta. Has recommended a health care service or treatment that the physician certifies, in writing, is likely to be more beneficial to the covered person, in the physician’s opinion, than any available standard health care services or treatments; or\n\t\t\t\tb. Who is a licensed, board certified, or board eligible physician qualified to practice in the area of medicine appropriate to treat the covered person’s condition, has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested is likely to be more beneficial to the covered person than any available standard health care services or treatments;5\n\nThe covered person has exhausted or is deemed to have exhausted the health carrier’s internal appeal process; and6\n\nThe covered person has provided all the required information and forms that are necessary to process an external review.E\n\nWithin one business day after completion of the preliminary review, the health carrier shall notify in writing the Commission and the covered person and his authorized representative, if any, whether the request is complete and eligible for external review. The following shall apply with regard to such requests:1\n\nIf the request is not complete, the health carrier shall inform in writing the Commission, the covered person, and his authorized representative, if any, and include in the notice what information or materials are needed to make the request complete. If the request is not eligible for external review, the health carrier shall inform the covered person, his authorized representative, if any, and the Commission in writing and include in the notice the reasons for its ineligibility. Such notice shall include a statement informing the covered person and his authorized representative, if any, that the health carrier’s determination of ineligibility may be appealed to the Commission; and2\n\nIf the health carrier makes an ineligibility determination, the Commission may determine that a request is eligible for external review and require that it be referred for external review. In making this determination, the Commission’s decision shall be made in accordance with the terms of the covered person’s health benefit plan and the requirements of subsection D.F\n\nWithin one business day after the receipt of the notice from the health carrier, the Commission shall assign an independent review organization to conduct the external review and notify in writing the health carrier, the covered person, and his authorized representative, if any, of the request’s eligibility and acceptance for external review, and the name of the assigned independent review organization. The following shall apply with regard to such an external review:1\n\nThe Commission shall include in such notice a statement that the covered person or his authorized representative, if any, may submit in writing to the assigned independent review organization, within five business days following the date of receipt, additional information that the independent review organization shall consider when conducting the external review;2\n\nWithin one business day after the receipt of such notice, the assigned independent review organization shall select one or more clinical reviewers, as it determines is appropriate, to conduct the external review; and3\n\nIn selecting clinical reviewers, the assigned independent review organization shall select physicians or other health care professionals who meet the minimum qualifications of § 38.2-3565 and, through clinical experience in the past three years, are experts in the treatment of the covered person’s condition and knowledgeable about the recommended or requested health care service or treatment. Neither the covered person, his authorized representative, if any, nor the health carrier shall choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review.G\n\nWithin five business days after the date of receipt of the notice from the Commission, the health carrier or its designee utilization review entity shall provide to the assigned independent review organization the documents and any information considered in making the adverse determination or the final adverse determination. Failure by the health carrier or its designee utilization review entity to provide the documents and information within the required time specified shall not delay the conduct of the external review. If the health carrier or its designee utilization review entity has failed to provide the documents and information within the required time specified, the assigned independent review entity may terminate the external review and make a decision to reverse the adverse determination or final adverse determination. Promptly upon making such decision, the independent review organization shall notify the covered person, his authorized representative, if any, the health carrier, and the Commission.H\n\nEach clinical reviewer selected shall review all of the information and documents timely received from the health carrier and any other information submitted in writing by the covered person or his authorized representative. The assigned independent review organization is not required to, but may, accept and consider information submitted late from the covered person or his authorized representative, if any. Upon receipt of any information submitted by the covered person or his authorized representative, within one business day after the receipt of the information, the assigned independent review organization shall forward the information to the health carrier.I\n\nUpon receipt of the information from the assigned independent review organization, the health carrier may reconsider its adverse determination or final adverse determination. Reconsideration by the health carrier of its adverse determination or final adverse determination shall not delay or terminate the external review. The external review may be terminated only if the health carrier decides to reverse its adverse determination or final adverse determination and provide coverage or payment for the recommended or requested health care service or treatment. Promptly upon making the decision to reverse its adverse determination or final adverse determination, the health carrier shall notify the covered person, his authorized representative, if any, the assigned independent review organization, and the Commission in writing of its decision. Upon receipt of notice of the health carrier’s decision to reverse its adverse determination or final adverse determination, the assigned independent review organization shall terminate the external review.J\n\nTo the extent the information or documents are available and the reviewer considers appropriate, each clinical reviewer shall also consider the following in reaching an opinion:1\n\nThe covered person’s pertinent medical records;2\n\nThe attending physician’s or health care professional’s recommendation;3\n\nConsulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person, his authorized representative, or the covered person’s treating physician or health care professional;4\n\nWhether the recommended or requested health care service or treatment is a covered service except for the health carrier’s determination that the service or treatment is experimental or investigational; and5\n\nWhether the recommended or requested health care service or treatment has been approved by the federal Food and Drug Administration, if applicable, for the condition, or medical or scientific evidence or evidence-based standards demonstrate that the expected benefits of the recommended or requested health care service or treatment is more likely than not to be beneficial to the covered person than any available standard health care service or treatment and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments.K\n\nWithin 20 days after being selected to conduct a standard external review, each clinical reviewer shall provide an opinion to the assigned independent review organization on whether the recommended or requested health care service or treatment should be covered. Each clinical reviewer’s opinion shall be in writing and include the following information: a description of the covered person’s medical condition; a description of the indicators relevant to determining whether there is sufficient evidence to demonstrate that the recommended or requested health care service or treatment is more likely than not to be more beneficial to the covered person than any available standard health care services or treatments and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments; a description and analysis of any medical or scientific evidence considered in reaching the opinion; a description and analysis of any evidence-based standard; and information on the extent, if any, to which the reviewer’s rationale for the opinion regarding the recommended or requested health care service or treatment is based on (i) whether the health care service or treatment has been approved by the federal Food and Drug Administration for the condition or (ii) medical or scientific evidence or evidence-based standards that demonstrate the recommended or requested health care service or treatment is more likely than not to be more beneficial to the covered person than any available standard health care service or treatment and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments.L\n\nWithin 20 days after the date it receives an opinion from all clinical reviewers, the assigned independent review organization shall make a decision and provide written notice to the covered person, his authorized representative, if any, the health carrier, and the Commission. If:1\n\nA majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should be covered, the independent review organization shall make a decision to reverse the health carrier’s adverse determination or final adverse determination;2\n\nA majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should not be covered, the independent review organization shall make a decision to uphold the health carrier’s adverse determination or final adverse determination; or3\n\nThe clinical reviewers are evenly split as to whether the recommended or requested health care service or treatment should be covered, the independent review organization shall obtain the opinion of an additional clinical reviewer. The additional clinical reviewer selected shall use the same information as the original clinical reviewers. The selection of the additional clinical reviewer shall not extend the time within which the assigned independent review organization is required to make a decision.M\n\nThe independent review organization shall include in the notice required pursuant to subsection L a general description of the reason for the request for external review; the written opinion of each clinical reviewer, including the recommendation of each clinical reviewer as to whether the recommended or requested health care service or treatment should be covered and the rationale for the reviewer’s recommendation; the date the independent review organization was assigned by the Commission to conduct the external review; the date the external review was conducted; the date of its decision; the principal reason or reasons for its decision; and the rationale for its decision.N\n\nUpon receipt of a notice of a decision reversing the adverse determination or final adverse determination, the health carrier shall promptly approve coverage of the recommended or requested health care service or treatment.","order_by":null,"text":{"0":{"id":232208,"text":"Within 120 days after the date of receipt of a notice of the right to an external review of an adverse determination or final adverse determination that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, a covered person or his authorized representative may file a request for external review with the Commission.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":232209,"text":"A covered person or his authorized representative may make an oral request for an expedited external review of the adverse determination or final adverse determination if the covered person’s treating physician certifies, in writing, that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated. The following shall apply with regard to such requests for an expedited external review:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"B1"},"2":{"id":232210,"text":"Upon receipt of a request for an expedited external review, the Commission shall promptly notify the health carrier;","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B2"},"3":{"id":232211,"text":"Upon notice of the request for expedited external review, the health carrier shall promptly determine whether the request meets the eligibility requirements in subsection D. The health carrier shall promptly notify the Commission and the covered person and his authorized representative, if any, of its eligibility determination. Such notice shall include a statement informing the covered person and his authorized representative, if any, that a health carrier’s ineligibility determination may be appealed to the Commission;","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B1","next_prefix":"B3"},"4":{"id":232212,"text":"If the health carrier makes an ineligibility determination, the Commission may determine that a request is eligible for external review and require that it be referred for external review. The Commission shall make such determination in accordance with the terms of the covered person’s health benefit plan and the requirements of subsection D;","type":"section","prefixes":["B","3"],"prefix":"3","entire_prefix":"B3","prefix_anchor":"B3","level":2,"prior_prefix":"B2","next_prefix":"B4"},"5":{"id":232213,"text":"Upon receipt of the notice that the expedited external review request meets the eligibility requirements, the Commission shall promptly assign an independent review organization to review the expedited request and notify the health carrier of the name of the assigned independent review organization;","type":"section","prefixes":["B","4"],"prefix":"4","entire_prefix":"B4","prefix_anchor":"B4","level":2,"prior_prefix":"B3","next_prefix":"B5"},"6":{"id":232214,"text":"Promptly upon receipt of the notice of the assigned independent review organization, the health carrier or its designee utilization review entity shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination to the assigned independent review organization electronically, by telephone, facsimile, or any other available expeditious method;","type":"section","prefixes":["B","5"],"prefix":"5","entire_prefix":"B5","prefix_anchor":"B5","level":2,"prior_prefix":"B4","next_prefix":"B6"},"7":{"id":232215,"text":"Upon receipt of the notice from the Commission, the assigned independent review organization shall promptly assign one or more clinical reviewers in accordance with the provisions of subdivision F 3 to conduct the external review;","type":"section","prefixes":["B","6"],"prefix":"6","entire_prefix":"B6","prefix_anchor":"B6","level":2,"prior_prefix":"B5","next_prefix":"B7"},"8":{"id":232216,"text":"In reaching an opinion, each clinical reviewer shall also consider the documents listed in subsection J. Each clinical reviewer shall provide an opinion orally or in writing to the assigned independent review organization as expeditiously as the covered person’s medical condition or circumstances require, but in no event more than five calendar days after being selected. If the opinion provided was not in writing, within 48 hours following the date of the opinion the clinical reviewer shall provide a written opinion to the assigned independent review organization. The written opinion shall include the information described in subsection K. Recommendations from more than one clinical reviewer shall meet the provisions of subsection L; and","type":"section","prefixes":["B","7"],"prefix":"7","entire_prefix":"B7","prefix_anchor":"B7","level":2,"prior_prefix":"B6","next_prefix":"B8"},"9":{"id":232217,"text":"Within 48 hours after the date it receives an opinion from all clinical reviewers, the assigned independent review organization shall make a decision and provide notice of the decision orally or in writing to the covered person, his authorized representative, if any, the health carrier, and the Commission. If the notice was not in writing, within 48 hours after the date of the notice, the assigned independent review organization shall provide written confirmation of the decision to the covered person, his authorized representative, if any, the health carrier, and the Commission. The decision shall include the information described in subsection M.","type":"section","prefixes":["B","8"],"prefix":"8","entire_prefix":"B8","prefix_anchor":"B8","level":2,"prior_prefix":"B7","next_prefix":"C"},"10":{"id":232218,"text":"Within one business day after the date of receipt of the request for a standard external review, the Commission shall notify the health carrier.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B8","next_prefix":"D"},"11":{"id":232219,"text":"Within five business days following the date of receipt of such notice, the health carrier shall conduct and complete a preliminary review of the request to determine whether:","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"D1"},"12":{"id":232220,"text":"The individual is or was a covered person in the health benefit plan at the time the health care service or treatment was recommended or requested or, in the case of a retrospective review, was a covered person in the health benefit plan at the time the health care service or treatment was provided;","type":"section","prefixes":["D","1"],"prefix":"1","entire_prefix":"D1","prefix_anchor":"D1","level":2,"prior_prefix":"D","next_prefix":"D2"},"13":{"id":232221,"text":"The recommended or requested health care service or treatment is a covered service except for the health carrier’s determination that the service or treatment is experimental or investigational for the particular medical condition and is not explicitly listed as an excluded benefit under the covered person’s health benefit plan;","type":"section","prefixes":["D","2"],"prefix":"2","entire_prefix":"D2","prefix_anchor":"D2","level":2,"prior_prefix":"D1","next_prefix":"D3"},"14":{"id":232222,"text":"The covered person’s treating physician has certified that one of the following situations is applicable:\n\t\t\t\ta. Standard health care services or treatments have not been effective in improving the condition of the covered person;\n\t\t\t\tb. Standard health care services or treatments are not medically appropriate for the covered person; or\n\t\t\t\tc. There is no available standard health care service or treatment covered that is more beneficial than the recommended or requested health care service or treatment;","type":"section","prefixes":["D","3"],"prefix":"3","entire_prefix":"D3","prefix_anchor":"D3","level":2,"prior_prefix":"D2","next_prefix":"D4"},"15":{"id":232223,"text":"The covered person’s treating physician:\n\t\t\t\ta. Has recommended a health care service or treatment that the physician certifies, in writing, is likely to be more beneficial to the covered person, in the physician’s opinion, than any available standard health care services or treatments; or\n\t\t\t\tb. Who is a licensed, board certified, or board eligible physician qualified to practice in the area of medicine appropriate to treat the covered person’s condition, has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested is likely to be more beneficial to the covered person than any available standard health care services or treatments;","type":"section","prefixes":["D","4"],"prefix":"4","entire_prefix":"D4","prefix_anchor":"D4","level":2,"prior_prefix":"D3","next_prefix":"D5"},"16":{"id":232224,"text":"The covered person has exhausted or is deemed to have exhausted the health carrier’s internal appeal process; and","type":"section","prefixes":["D","5"],"prefix":"5","entire_prefix":"D5","prefix_anchor":"D5","level":2,"prior_prefix":"D4","next_prefix":"D6"},"17":{"id":232225,"text":"The covered person has provided all the required information and forms that are necessary to process an external review.","type":"section","prefixes":["D","6"],"prefix":"6","entire_prefix":"D6","prefix_anchor":"D6","level":2,"prior_prefix":"D5","next_prefix":"E"},"18":{"id":232226,"text":"Within one business day after completion of the preliminary review, the health carrier shall notify in writing the Commission and the covered person and his authorized representative, if any, whether the request is complete and eligible for external review. The following shall apply with regard to such requests:","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D6","next_prefix":"E1"},"19":{"id":232227,"text":"If the request is not complete, the health carrier shall inform in writing the Commission, the covered person, and his authorized representative, if any, and include in the notice what information or materials are needed to make the request complete. If the request is not eligible for external review, the health carrier shall inform the covered person, his authorized representative, if any, and the Commission in writing and include in the notice the reasons for its ineligibility. Such notice shall include a statement informing the covered person and his authorized representative, if any, that the health carrier’s determination of ineligibility may be appealed to the Commission; and","type":"section","prefixes":["E","1"],"prefix":"1","entire_prefix":"E1","prefix_anchor":"E1","level":2,"prior_prefix":"E","next_prefix":"E2"},"20":{"id":232228,"text":"If the health carrier makes an ineligibility determination, the Commission may determine that a request is eligible for external review and require that it be referred for external review. In making this determination, the Commission’s decision shall be made in accordance with the terms of the covered person’s health benefit plan and the requirements of subsection D.","type":"section","prefixes":["E","2"],"prefix":"2","entire_prefix":"E2","prefix_anchor":"E2","level":2,"prior_prefix":"E1","next_prefix":"F"},"21":{"id":232229,"text":"Within one business day after the receipt of the notice from the health carrier, the Commission shall assign an independent review organization to conduct the external review and notify in writing the health carrier, the covered person, and his authorized representative, if any, of the request’s eligibility and acceptance for external review, and the name of the assigned independent review organization. The following shall apply with regard to such an external review:","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E2","next_prefix":"F1"},"22":{"id":232230,"text":"The Commission shall include in such notice a statement that the covered person or his authorized representative, if any, may submit in writing to the assigned independent review organization, within five business days following the date of receipt, additional information that the independent review organization shall consider when conducting the external review;","type":"section","prefixes":["F","1"],"prefix":"1","entire_prefix":"F1","prefix_anchor":"F1","level":2,"prior_prefix":"F","next_prefix":"F2"},"23":{"id":232231,"text":"Within one business day after the receipt of such notice, the assigned independent review organization shall select one or more clinical reviewers, as it determines is appropriate, to conduct the external review; and","type":"section","prefixes":["F","2"],"prefix":"2","entire_prefix":"F2","prefix_anchor":"F2","level":2,"prior_prefix":"F1","next_prefix":"F3"},"24":{"id":232232,"text":"In selecting clinical reviewers, the assigned independent review organization shall select physicians or other health care professionals who meet the minimum qualifications of § 38.2-3565 and, through clinical experience in the past three years, are experts in the treatment of the covered person’s condition and knowledgeable about the recommended or requested health care service or treatment. Neither the covered person, his authorized representative, if any, nor the health carrier shall choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review.","type":"section","prefixes":["F","3"],"prefix":"3","entire_prefix":"F3","prefix_anchor":"F3","level":2,"prior_prefix":"F2","next_prefix":"G"},"25":{"id":232233,"text":"Within five business days after the date of receipt of the notice from the Commission, the health carrier or its designee utilization review entity shall provide to the assigned independent review organization the documents and any information considered in making the adverse determination or the final adverse determination. Failure by the health carrier or its designee utilization review entity to provide the documents and information within the required time specified shall not delay the conduct of the external review. If the health carrier or its designee utilization review entity has failed to provide the documents and information within the required time specified, the assigned independent review entity may terminate the external review and make a decision to reverse the adverse determination or final adverse determination. Promptly upon making such decision, the independent review organization shall notify the covered person, his authorized representative, if any, the health carrier, and the Commission.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F3","next_prefix":"H"},"26":{"id":232234,"text":"Each clinical reviewer selected shall review all of the information and documents timely received from the health carrier and any other information submitted in writing by the covered person or his authorized representative. The assigned independent review organization is not required to, but may, accept and consider information submitted late from the covered person or his authorized representative, if any. Upon receipt of any information submitted by the covered person or his authorized representative, within one business day after the receipt of the information, the assigned independent review organization shall forward the information to the health carrier.","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G","next_prefix":"I"},"27":{"id":232235,"text":"Upon receipt of the information from the assigned independent review organization, the health carrier may reconsider its adverse determination or final adverse determination. Reconsideration by the health carrier of its adverse determination or final adverse determination shall not delay or terminate the external review. The external review may be terminated only if the health carrier decides to reverse its adverse determination or final adverse determination and provide coverage or payment for the recommended or requested health care service or treatment. Promptly upon making the decision to reverse its adverse determination or final adverse determination, the health carrier shall notify the covered person, his authorized representative, if any, the assigned independent review organization, and the Commission in writing of its decision. Upon receipt of notice of the health carrier’s decision to reverse its adverse determination or final adverse determination, the assigned independent review organization shall terminate the external review.","type":"section","prefixes":["I"],"prefix":"I","entire_prefix":"I","prefix_anchor":"I","level":1,"prior_prefix":"H","next_prefix":"J"},"28":{"id":232236,"text":"To the extent the information or documents are available and the reviewer considers appropriate, each clinical reviewer shall also consider the following in reaching an opinion:","type":"section","prefixes":["J"],"prefix":"J","entire_prefix":"J","prefix_anchor":"J","level":1,"prior_prefix":"I","next_prefix":"J1"},"29":{"id":232237,"text":"The covered person’s pertinent medical records;","type":"section","prefixes":["J","1"],"prefix":"1","entire_prefix":"J1","prefix_anchor":"J1","level":2,"prior_prefix":"J","next_prefix":"J2"},"30":{"id":232238,"text":"The attending physician’s or health care professional’s recommendation;","type":"section","prefixes":["J","2"],"prefix":"2","entire_prefix":"J2","prefix_anchor":"J2","level":2,"prior_prefix":"J1","next_prefix":"J3"},"31":{"id":232239,"text":"Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person, his authorized representative, or the covered person’s treating physician or health care professional;","type":"section","prefixes":["J","3"],"prefix":"3","entire_prefix":"J3","prefix_anchor":"J3","level":2,"prior_prefix":"J2","next_prefix":"J4"},"32":{"id":232240,"text":"Whether the recommended or requested health care service or treatment is a covered service except for the health carrier’s determination that the service or treatment is experimental or investigational; and","type":"section","prefixes":["J","4"],"prefix":"4","entire_prefix":"J4","prefix_anchor":"J4","level":2,"prior_prefix":"J3","next_prefix":"J5"},"33":{"id":232241,"text":"Whether the recommended or requested health care service or treatment has been approved by the federal Food and Drug Administration, if applicable, for the condition, or medical or scientific evidence or evidence-based standards demonstrate that the expected benefits of the recommended or requested health care service or treatment is more likely than not to be beneficial to the covered person than any available standard health care service or treatment and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments.","type":"section","prefixes":["J","5"],"prefix":"5","entire_prefix":"J5","prefix_anchor":"J5","level":2,"prior_prefix":"J4","next_prefix":"K"},"34":{"id":232242,"text":"Within 20 days after being selected to conduct a standard external review, each clinical reviewer shall provide an opinion to the assigned independent review organization on whether the recommended or requested health care service or treatment should be covered. Each clinical reviewer’s opinion shall be in writing and include the following information: a description of the covered person’s medical condition; a description of the indicators relevant to determining whether there is sufficient evidence to demonstrate that the recommended or requested health care service or treatment is more likely than not to be more beneficial to the covered person than any available standard health care services or treatments and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments; a description and analysis of any medical or scientific evidence considered in reaching the opinion; a description and analysis of any evidence-based standard; and information on the extent, if any, to which the reviewer’s rationale for the opinion regarding the recommended or requested health care service or treatment is based on (i) whether the health care service or treatment has been approved by the federal Food and Drug Administration for the condition or (ii) medical or scientific evidence or evidence-based standards that demonstrate the recommended or requested health care service or treatment is more likely than not to be more beneficial to the covered person than any available standard health care service or treatment and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments.","type":"section","prefixes":["K"],"prefix":"K","entire_prefix":"K","prefix_anchor":"K","level":1,"prior_prefix":"J5","next_prefix":"L"},"35":{"id":232243,"text":"Within 20 days after the date it receives an opinion from all clinical reviewers, the assigned independent review organization shall make a decision and provide written notice to the covered person, his authorized representative, if any, the health carrier, and the Commission. If:","type":"section","prefixes":["L"],"prefix":"L","entire_prefix":"L","prefix_anchor":"L","level":1,"prior_prefix":"K","next_prefix":"L1"},"36":{"id":232244,"text":"A majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should be covered, the independent review organization shall make a decision to reverse the health carrier’s adverse determination or final adverse determination;","type":"section","prefixes":["L","1"],"prefix":"1","entire_prefix":"L1","prefix_anchor":"L1","level":2,"prior_prefix":"L","next_prefix":"L2"},"37":{"id":232245,"text":"A majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should not be covered, the independent review organization shall make a decision to uphold the health carrier’s adverse determination or final adverse determination; or","type":"section","prefixes":["L","2"],"prefix":"2","entire_prefix":"L2","prefix_anchor":"L2","level":2,"prior_prefix":"L1","next_prefix":"L3"},"38":{"id":232246,"text":"The clinical reviewers are evenly split as to whether the recommended or requested health care service or treatment should be covered, the independent review organization shall obtain the opinion of an additional clinical reviewer. The additional clinical reviewer selected shall use the same information as the original clinical reviewers. The selection of the additional clinical reviewer shall not extend the time within which the assigned independent review organization is required to make a decision.","type":"section","prefixes":["L","3"],"prefix":"3","entire_prefix":"L3","prefix_anchor":"L3","level":2,"prior_prefix":"L2","next_prefix":"M"},"39":{"id":232247,"text":"The independent review organization shall include in the notice required pursuant to subsection L a general description of the reason for the request for external review; the written opinion of each clinical reviewer, including the recommendation of each clinical reviewer as to whether the recommended or requested health care service or treatment should be covered and the rationale for the reviewer’s recommendation; the date the independent review organization was assigned by the Commission to conduct the external review; the date the external review was conducted; the date of its decision; the principal reason or reasons for its decision; and the rationale for its decision.","type":"section","prefixes":["M"],"prefix":"M","entire_prefix":"M","prefix_anchor":"M","level":1,"prior_prefix":"L3","next_prefix":"N"},"40":{"id":232248,"text":"Upon receipt of a notice of a decision reversing the adverse determination or final adverse determination, the health carrier shall promptly approve coverage of the recommended or requested health care service or treatment.","type":"section","prefixes":["N"],"prefix":"N","entire_prefix":"N","prefix_anchor":"N","level":1,"prior_prefix":"M"}},"ancestry":[{"id":14588,"edition_id":1,"name":"Health Carrier Internal Appeal Process and External Review","identifier":"35.1","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:48:47","date_modified":"2026-06-26 03:48:47","permalink":{"id":215937,"object_type":"structure","relational_id":14588,"identifier":"35.1","token":"38.2\/35.1","url":"\/38.2\/35.1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12698,"edition_id":1,"name":"Insurance","identifier":"38.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:49","date_modified":"2026-06-26 03:43:49","permalink":{"id":210661,"object_type":"structure","relational_id":12698,"identifier":"38.2","token":"38.2","url":"\/38.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":58140,"structure_id":14588,"section_number":"38.2-3556","catch_line":"Definitions","url":"\/38.2-3556\/","token":"38.2\/35.1\/38.2-3556","metadata":false},{"id":56086,"structure_id":14588,"section_number":"38.2-3557","catch_line":"Scope of chapter","url":"\/38.2-3557\/","token":"38.2\/35.1\/38.2-3557","metadata":false},{"id":56843,"structure_id":14588,"section_number":"38.2-3558","catch_line":"Health carrier's internal appeal process","url":"\/38.2-3558\/","token":"38.2\/35.1\/38.2-3558","metadata":false},{"id":77920,"structure_id":14588,"section_number":"38.2-3559","catch_line":"Notice of right to external review","url":"\/38.2-3559\/","token":"38.2\/35.1\/38.2-3559","metadata":false},{"id":65207,"structure_id":14588,"section_number":"38.2-3560","catch_line":"Exhaustion of internal appeal process","url":"\/38.2-3560\/","token":"38.2\/35.1\/38.2-3560","metadata":false},{"id":66856,"structure_id":14588,"section_number":"38.2-3561","catch_line":"Standard external review","url":"\/38.2-3561\/","token":"38.2\/35.1\/38.2-3561","metadata":false},{"id":83961,"structure_id":14588,"section_number":"38.2-3562","catch_line":"Expedited external review","url":"\/38.2-3562\/","token":"38.2\/35.1\/38.2-3562","metadata":false},{"id":63745,"structure_id":14588,"section_number":"38.2-3563","catch_line":"External review of experimental or investigational treatment adverse determinations","url":"\/38.2-3563\/","token":"38.2\/35.1\/38.2-3563","metadata":false},{"id":78633,"structure_id":14588,"section_number":"38.2-3564","catch_line":"Binding nature of external review decision","url":"\/38.2-3564\/","token":"38.2\/35.1\/38.2-3564","metadata":false},{"id":63044,"structure_id":14588,"section_number":"38.2-3565","catch_line":"Minimum qualifications for independent review organizations","url":"\/38.2-3565\/","token":"38.2\/35.1\/38.2-3565","metadata":false},{"id":59040,"structure_id":14588,"section_number":"38.2-3566","catch_line":"Approval of independent review organizations","url":"\/38.2-3566\/","token":"38.2\/35.1\/38.2-3566","metadata":false},{"id":79665,"structure_id":14588,"section_number":"38.2-3567","catch_line":"Independent review organizations to be held harmless","url":"\/38.2-3567\/","token":"38.2\/35.1\/38.2-3567","metadata":false},{"id":81396,"structure_id":14588,"section_number":"38.2-3568","catch_line":"External review reporting requirements","url":"\/38.2-3568\/","token":"38.2\/35.1\/38.2-3568","metadata":false},{"id":75481,"structure_id":14588,"section_number":"38.2-3569","catch_line":"Funding of external review","url":"\/38.2-3569\/","token":"38.2\/35.1\/38.2-3569","metadata":false},{"id":83489,"structure_id":14588,"section_number":"38.2-3570","catch_line":"Disclosure requirements","url":"\/38.2-3570\/","token":"38.2\/35.1\/38.2-3570","metadata":false},{"id":56157,"structure_id":14588,"section_number":"38.2-3571","catch_line":"Regulations","url":"\/38.2-3571\/","token":"38.2\/35.1\/38.2-3571","metadata":false}],"previous_section":{"id":83961,"structure_id":14588,"section_number":"38.2-3562","catch_line":"Expedited external review","url":"\/38.2-3562\/","token":"38.2\/35.1\/38.2-3562","metadata":false},"next_section":{"id":78633,"structure_id":14588,"section_number":"38.2-3564","catch_line":"Binding nature of external review decision","url":"\/38.2-3564\/","token":"38.2\/35.1\/38.2-3564","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3563\/","history_text":"

This law was first created in 2011. The record of its establishment is cataloged in chapter 788<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year.<\/p>","references":[{"id":77920,"section_number":"38.2-3559","catch_line":"Notice of right to external review","order_by":null,"url":"\/38.2-3559\/"}],"refers_to":[{"id":63044,"section_number":"38.2-3565","catch_line":"Minimum qualifications for independent review organizations","order_by":null,"url":"\/38.2-3565\/"}],"permalink":{"id":215967,"object_type":"law","relational_id":63745,"identifier":"38.2-3563","token":"38.2\/35.1\/38.2-3563","url":"\/38.2-3563\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3563\/","token":"38.2\/35.1\/38.2-3563","dublin_core":{"Title":"External review of experimental or investigational treatment adverse determinations","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3563","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> Within 120 days after the date of receipt of a notice of the right to an external review of an adverse determination or final adverse determination<\/span> that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, a covered person<\/span> or his authorized representative<\/span> may file a request for external review with the Commission<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> A covered person<\/span> or his authorized representative<\/span> may make an oral request for an expedited external review of the adverse determination or final adverse determination<\/span> if the covered person<\/span>’s treating physician certifies, in writing, that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated. The following shall apply with regard to such requests for an expedited external review: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Upon receipt of a request for an expedited external review, the Commission<\/span> shall promptly notify the health carrier<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Upon notice of the request for expedited external review, the health carrier<\/span> shall promptly determine whether the request meets the eligibility requirements in subsection D. The health carrier<\/span> shall promptly notify the Commission<\/span> and the covered person<\/span> and his authorized representative<\/span>, if any, of its eligibility determination. Such notice shall include a statement informing the covered person<\/span> and his authorized representative<\/span>, if any, that a health carrier<\/span>’s ineligibility determination may be appealed to the Commission<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> If the health carrier<\/span> makes an ineligibility determination, the Commission<\/span> may determine that a request is eligible for external review and require that it be referred for external review. The Commission<\/span> shall make such determination in accordance with the terms of the covered person<\/span>’s health benefit plan<\/span> and the requirements of subsection D; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Upon receipt of the notice that the expedited external review request meets the eligibility requirements, the Commission<\/span> shall promptly assign an independent review organization<\/span> to review the expedited request and notify the health carrier<\/span> of the name of the assigned independent review organization<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

5.<\/span> Promptly upon receipt of the notice of the assigned independent review organization<\/span>, the health carrier<\/span> or its designee utilization review entity<\/span> shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination<\/span> to the assigned independent review organization<\/span> electronically, by telephone, facsimile, or any other available expeditious method; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

6.<\/span> Upon receipt of the notice from the Commission<\/span>, the assigned independent review organization<\/span> shall promptly assign one or more clinical reviewers in accordance with the provisions of subdivision F 3 to conduct the external review; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

7.<\/span> In reaching an opinion<\/span>, each clinical reviewer shall also consider the documents listed in subsection J. Each clinical reviewer shall provide an opinion<\/span> orally or in writing to the assigned independent review organization<\/span> as expeditiously as the covered person<\/span>’s medical condition or circumstances require, but in no event more than five calendar days after being selected. If the opinion<\/span> provided was not in writing, within 48 hours following the date of the opinion<\/span> the clinical reviewer shall provide a written opinion<\/span> to the assigned independent review organization<\/span>. The written opinion<\/span> shall include the information described in subsection K. Recommendations from more than one clinical reviewer shall meet the provisions of subsection L; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

8.<\/span> Within 48 hours after the date it receives an opinion<\/span> from all clinical reviewers, the assigned independent review organization<\/span> shall make a decision and provide notice of the decision orally or in writing to the covered person<\/span>, his authorized representative<\/span>, if any, the health carrier<\/span>, and the Commission<\/span>. If the notice was not in writing, within 48 hours after the date of the notice, the assigned independent review organization<\/span> shall provide written confirmation of the decision to the covered person<\/span>, his authorized representative<\/span>, if any, the health carrier<\/span>, and the Commission<\/span>. The decision shall include the information described in subsection M. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Within one business day after the date of receipt of the request for a standard external review, the Commission<\/span> shall notify the health carrier<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> Within five business days following the date of receipt of such notice, the health carrier<\/span> shall conduct and complete a preliminary review of the request to determine whether: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> The individual is or was a covered person<\/span> in the health benefit plan<\/span> at the time the health care service or treatment was recommended or requested or, in the case of a retrospective review<\/span>, was a covered person<\/span> in the health benefit plan<\/span> at the time the health care service or treatment was provided; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> The recommended or requested health care service or treatment is a covered service except for the health carrier<\/span>’s determination that the service or treatment is experimental or investigational for the particular medical condition and is not explicitly listed as an excluded benefit under the covered person<\/span>’s health benefit plan<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> The covered person<\/span>’s treating physician has certified that one of the following situations is applicable:\n\t\t\t\ta. Standard health care services<\/span> or treatments have not been effective in improving the condition of the covered person<\/span>;\n\t\t\t\tb. Standard health care services<\/span> or treatments are not medically appropriate for the covered person<\/span>; or\n\t\t\t\tc. There is no available standard health care service or treatment covered that is more beneficial than the recommended or requested health care service or treatment; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> The covered person<\/span>’s treating physician:\n\t\t\t\ta. Has recommended a health care service or treatment that the physician certifies, in writing, is likely to be more beneficial to the covered person<\/span>, in the physician’s opinion<\/span>, than any available standard health care services<\/span> or treatments; or\n\t\t\t\tb. Who is a licensed, board certified, or board eligible physician qualified to practice in the area of medicine appropriate to treat the covered person<\/span>’s condition, has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested is likely to be more beneficial to the covered person<\/span> than any available standard health care services<\/span> or treatments; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

5.<\/span> The covered person<\/span> has exhausted or is deemed to have exhausted the health carrier<\/span>’s internal appeal<\/span> process; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

6.<\/span> The covered person<\/span> has provided all the required information and forms that are necessary to process an external review. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Within one business day after completion of the preliminary review, the health carrier<\/span> shall notify in writing the Commission<\/span> and the covered person<\/span> and his authorized representative<\/span>, if any, whether the request is complete and eligible for external review. The following shall apply with regard to such requests: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> If the request is not complete, the health carrier<\/span> shall inform in writing the Commission<\/span>, the covered person<\/span>, and his authorized representative<\/span>, if any, and include in the notice what information or materials<\/span> are needed to make the request complete. If the request is not eligible for external review, the health carrier<\/span> shall inform the covered person<\/span>, his authorized representative<\/span>, if any, and the Commission<\/span> in writing and include in the notice the reasons for its ineligibility. Such notice shall include a statement informing the covered person<\/span> and his authorized representative<\/span>, if any, that the health carrier<\/span>’s determination of ineligibility may be appealed to the Commission<\/span>; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> If the health carrier<\/span> makes an ineligibility determination, the Commission<\/span> may determine that a request is eligible for external review and require that it be referred for external review. In making this determination, the Commission<\/span>’s decision shall be made in accordance with the terms of the covered person<\/span>’s health benefit plan<\/span> and the requirements of subsection D. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> Within one business day after the receipt of the notice from the health carrier<\/span>, the Commission<\/span> shall assign an independent review organization<\/span> to conduct the external review and notify in writing the health carrier<\/span>, the covered person<\/span>, and his authorized representative<\/span>, if any, of the request’s eligibility and acceptance for external review, and the name of the assigned independent review organization<\/span>. The following shall apply with regard to such an external review: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> The Commission<\/span> shall include in such notice a statement that the covered person<\/span> or his authorized representative<\/span>, if any, may submit in writing to the assigned independent review organization<\/span>, within five business days following the date of receipt, additional information that the independent review organization<\/span> shall consider when conducting the external review; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Within one business day after the receipt of such notice, the assigned independent review organization<\/span> shall select one or more clinical reviewers, as it determines is appropriate, to conduct the external review; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> In selecting clinical reviewers, the assigned independent review organization<\/span> shall select physicians or other health care professionals<\/span> who meet the minimum qualifications of § 38.2-3565<\/a> and, through clinical experience in the past three years, are experts in the treatment of the covered person<\/span>’s condition and knowledgeable about the recommended or requested health care service or treatment. Neither the covered person<\/span>, his authorized representative<\/span>, if any, nor the health carrier<\/span> shall choose or control the choice of the physicians or other health care professionals<\/span> to be selected to conduct the external review. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> Within five business days after the date of receipt of the notice from the Commission<\/span>, the health carrier<\/span> or its designee utilization review entity<\/span> shall provide to the assigned independent review organization<\/span> the documents and any information considered in making the adverse determination or the final adverse determination<\/span>. Failure by the health carrier<\/span> or its designee utilization review entity<\/span> to provide the documents and information within the required time specified shall not delay the conduct of the external review. If the health carrier<\/span> or its designee utilization review entity<\/span> has failed to provide the documents and information within the required time specified, the assigned independent review entity may terminate the external review and make a decision to reverse<\/span> the adverse determination or final adverse determination<\/span>. Promptly upon making such decision, the independent review organization<\/span> shall notify the covered person<\/span>, his authorized representative<\/span>, if any, the health carrier<\/span>, and the Commission<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

H.<\/span> Each clinical reviewer selected shall review all of the information and documents timely received from the health carrier<\/span> and any other information submitted in writing by the covered person<\/span> or his authorized representative<\/span>. The assigned independent review organization<\/span> is not required to, but may, accept and consider information submitted late from the covered person<\/span> or his authorized representative<\/span>, if any. Upon receipt of any information submitted by the covered person<\/span> or his authorized representative<\/span>, within one business day after the receipt of the information, the assigned independent review organization<\/span> shall forward the information to the health carrier<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

I.<\/span> Upon receipt of the information from the assigned independent review organization<\/span>, the health carrier<\/span> may reconsider its adverse determination or final adverse determination<\/span>. Reconsideration by the health carrier<\/span> of its adverse determination or final adverse determination<\/span> shall not delay or terminate the external review. The external review may be terminated only if the health carrier<\/span> decides to reverse<\/span> its adverse determination or final adverse determination<\/span> and provide coverage or payment for the recommended or requested health care service or treatment. Promptly upon making the decision to reverse<\/span> its adverse determination or final adverse determination<\/span>, the health carrier<\/span> shall notify the covered person<\/span>, his authorized representative<\/span>, if any, the assigned independent review organization<\/span>, and the Commission<\/span> in writing of its decision. Upon receipt of notice of the health carrier<\/span>’s decision to reverse<\/span> its adverse determination or final adverse determination<\/span>, the assigned independent review organization<\/span> shall terminate the external review. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

J.<\/span> To the extent the information or documents are available and the reviewer considers appropriate, each clinical reviewer shall also consider the following in reaching an opinion<\/span>: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> The covered person<\/span>’s pertinent medical records; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> The attending physician’s or health care professional<\/span>’s recommendation; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Consulting reports from appropriate health care professionals<\/span> and other documents submitted by the health carrier<\/span>, covered person<\/span>, his authorized representative<\/span>, or the covered person<\/span>’s treating physician or health care professional<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Whether the recommended or requested health care service or treatment is a covered service except for the health carrier<\/span>’s determination that the service or treatment is experimental or investigational; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

5.<\/span> Whether the recommended or requested health care service or treatment has been approved by the federal Food and Drug Administration, if applicable, for the condition, or medical or scientific evidence<\/span> or evidence-based standards<\/span> demonstrate that the expected benefits<\/span> of the recommended or requested health care service or treatment is more likely than not to be beneficial to the covered person<\/span> than any available standard health care service or treatment and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services<\/span> or treatments. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

K.<\/span> Within 20 days after being selected to conduct a standard external review, each clinical reviewer shall provide an opinion<\/span> to the assigned independent review organization<\/span> on whether the recommended or requested health care service or treatment should be covered. Each clinical reviewer’s opinion<\/span> shall be in writing and include the following information: a description of the covered person<\/span>’s medical condition; a description of the indicators relevant to determining whether there is sufficient evidence to demonstrate that the recommended or requested health care service or treatment is more likely than not to be more beneficial to the covered person<\/span> than any available standard health care services<\/span> or treatments and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services<\/span> or treatments; a description and analysis of any medical or scientific evidence<\/span> considered in reaching the opinion<\/span>; a description and analysis of any evidence-based standard<\/span>; and information on the extent, if any, to which the reviewer’s rationale for the opinion<\/span> regarding the recommended or requested health care service or treatment is based on (i) whether the health care service or treatment has been approved by the federal Food and Drug Administration for the condition or (ii) medical or scientific evidence<\/span> or evidence-based standards<\/span> that demonstrate the recommended or requested health care service or treatment is more likely than not to be more beneficial to the covered person<\/span> than any available standard health care service or treatment and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services<\/span> or treatments. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

L.<\/span> Within 20 days after the date it receives an opinion<\/span> from all clinical reviewers, the assigned independent review organization<\/span> shall make a decision and provide written notice to the covered person<\/span>, his authorized representative<\/span>, if any, the health carrier<\/span>, and the Commission<\/span>. If: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> A majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should be covered, the independent review organization<\/span> shall make a decision to reverse<\/span> the health carrier<\/span>’s adverse determination or final adverse determination<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> A majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should not be covered, the independent review organization<\/span> shall make a decision to uphold<\/span> the health carrier<\/span>’s adverse determination or final adverse determination<\/span>; or <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> The clinical reviewers are evenly split as to whether the recommended or requested health care service or treatment should be covered, the independent review organization<\/span> shall obtain the opinion<\/span> of an additional clinical reviewer. The additional clinical reviewer selected shall use the same information as the original clinical reviewers. The selection of the additional clinical reviewer shall not extend the time within which the assigned independent review organization<\/span> is required to make a decision. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

M.<\/span> The independent review organization<\/span> shall include in the notice required pursuant to subsection L a general description of the reason for the request for external review; the written opinion<\/span> of each clinical reviewer, including the recommendation of each clinical reviewer as to whether the recommended or requested health care service or treatment should be covered and the rationale for the reviewer’s recommendation; the date the independent review organization<\/span> was assigned by the Commission<\/span> to conduct the external review; the date the external review was conducted; the date of its decision; the principal reason or reasons for its decision; and the rationale for its decision. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

N.<\/span> Upon receipt of a notice of a decision reversing the adverse determination or final adverse determination<\/span>, the health carrier<\/span> shall promptly approve coverage of the recommended or requested health care service or treatment. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nEXTERNAL REVIEW OF EXPERIMENTAL OR INVESTIGATIONAL TREATMENT ADVERSE\nDETERMINATIONS (\u00a7 38.2-3563)\n\nA. Within 120 days after the date of receipt of a notice of the right to an\nexternal review of an adverse determination or final adverse determination that\ninvolves a denial of coverage based on a determination that the health care\nservice or treatment recommended or requested is experimental or\ninvestigational, a covered person or his authorized representative may file a\nrequest for external review with the Commission.\n\nB. A covered person or his authorized representative may make an oral request\nfor an expedited external review of the adverse determination or final adverse\ndetermination if the covered person’s treating physician certifies, in\nwriting, that the recommended or requested health care service or treatment\nwould be significantly less effective if not promptly initiated. The following\nshall apply with regard to such requests for an expedited external review:\n\n 1. Upon receipt of a request for an expedited external review, the Commission\n shall promptly notify the health carrier;\n\n 2. Upon notice of the request for expedited external review, the health\n carrier shall promptly determine whether the request meets the eligibility\n requirements in subsection D. The health carrier shall promptly notify the\n Commission and the covered person and his authorized representative, if any,\n of its eligibility determination. Such notice shall include a statement\n informing the covered person and his authorized representative, if any, that a\n health carrier’s ineligibility determination may be appealed to the\n Commission;\n\n 3. If the health carrier makes an ineligibility determination, the Commission\n may determine that a request is eligible for external review and require that\n it be referred for external review. The Commission shall make such\n determination in accordance with the terms of the covered person’s\n health benefit plan and the requirements of subsection D;\n\n 4. Upon receipt of the notice that the expedited external review request meets\n the eligibility requirements, the Commission shall promptly assign an\n independent review organization to review the expedited request and notify the\n health carrier of the name of the assigned independent review organization;\n\n 5. Promptly upon receipt of the notice of the assigned independent review\n organization, the health carrier or its designee utilization review entity\n shall provide or transmit all necessary documents and information considered\n in making the adverse determination or final adverse determination to the\n assigned independent review organization electronically, by telephone,\n facsimile, or any other available expeditious method;\n\n 6. Upon receipt of the notice from the Commission, the assigned independent\n review organization shall promptly assign one or more clinical reviewers in\n accordance with the provisions of subdivision F 3 to conduct the external\n review;\n\n 7. In reaching an opinion, each clinical reviewer shall also consider the\n documents listed in subsection J. Each clinical reviewer shall provide an\n opinion orally or in writing to the assigned independent review organization\n as expeditiously as the covered person’s medical condition or\n circumstances require, but in no event more than five calendar days after\n being selected. If the opinion provided was not in writing, within 48 hours\n following the date of the opinion the clinical reviewer shall provide a\n written opinion to the assigned independent review organization. The written\n opinion shall include the information described in subsection K.\n Recommendations from more than one clinical reviewer shall meet the provisions\n of subsection L; and\n\n 8. Within 48 hours after the date it receives an opinion from all clinical\n reviewers, the assigned independent review organization shall make a decision\n and provide notice of the decision orally or in writing to the covered person,\n his authorized representative, if any, the health carrier, and the Commission.\n If the notice was not in writing, within 48 hours after the date of the\n notice, the assigned independent review organization shall provide written\n confirmation of the decision to the covered person, his authorized\n representative, if any, the health carrier, and the Commission. The decision\n shall include the information described in subsection M.\n\nC. Within one business day after the date of receipt of the request for a\nstandard external review, the Commission shall notify the health carrier.\n\nD. Within five business days following the date of receipt of such notice, the\nhealth carrier shall conduct and complete a preliminary review of the request to\ndetermine whether:\n\n 1. The individual is or was a covered person in the health benefit plan at the\n time the health care service or treatment was recommended or requested or, in\n the case of a retrospective review, was a covered person in the health benefit\n plan at the time the health care service or treatment was provided;\n\n 2. The recommended or requested health care service or treatment is a covered\n service except for the health carrier’s determination that the service\n or treatment is experimental or investigational for the particular medical\n condition and is not explicitly listed as an excluded benefit under the\n covered person’s health benefit plan;\n\n 3. The covered person’s treating physician has certified that one of the\n following situations is applicable:\n \t\t\t\ta. Standard health care services or treatments have not been effective in\n improving the condition of the covered person;\n \t\t\t\tb. Standard health care services or treatments are not medically\n appropriate for the covered person; or\n \t\t\t\tc. There is no available standard health care service or treatment covered\n that is more beneficial than the recommended or requested health care service\n or treatment;\n\n 4. The covered person’s treating physician:\n \t\t\t\ta. Has recommended a health care service or treatment that the physician\n certifies, in writing, is likely to be more beneficial to the covered person,\n in the physician’s opinion, than any available standard health care\n services or treatments; or\n \t\t\t\tb. Who is a licensed, board certified, or board eligible physician\n qualified to practice in the area of medicine appropriate to treat the covered\n person’s condition, has certified in writing that scientifically valid\n studies using accepted protocols demonstrate that the health care service or\n treatment requested is likely to be more beneficial to the covered person than\n any available standard health care services or treatments;\n\n 5. The covered person has exhausted or is deemed to have exhausted the health\n carrier’s internal appeal process; and\n\n 6. The covered person has provided all the required information and forms that\n are necessary to process an external review.\n\nE. Within one business day after completion of the preliminary review, the\nhealth carrier shall notify in writing the Commission and the covered person and\nhis authorized representative, if any, whether the request is complete and\neligible for external review. The following shall apply with regard to such\nrequests:\n\n 1. If the request is not complete, the health carrier shall inform in writing\n the Commission, the covered person, and his authorized representative, if any,\n and include in the notice what information or materials are needed to make the\n request complete. If the request is not eligible for external review, the\n health carrier shall inform the covered person, his authorized representative,\n if any, and the Commission in writing and include in the notice the reasons\n for its ineligibility. Such notice shall include a statement informing the\n covered person and his authorized representative, if any, that the health\n carrier’s determination of ineligibility may be appealed to the\n Commission; and\n\n 2. If the health carrier makes an ineligibility determination, the Commission\n may determine that a request is eligible for external review and require that\n it be referred for external review. In making this determination, the\n Commission’s decision shall be made in accordance with the terms of the\n covered person’s health benefit plan and the requirements of subsection\n D.\n\nF. Within one business day after the receipt of the notice from the health\ncarrier, the Commission shall assign an independent review organization to\nconduct the external review and notify in writing the health carrier, the\ncovered person, and his authorized representative, if any, of the\nrequest’s eligibility and acceptance for external review, and the name of\nthe assigned independent review organization. The following shall apply with\nregard to such an external review:\n\n 1. The Commission shall include in such notice a statement that the covered\n person or his authorized representative, if any, may submit in writing to the\n assigned independent review organization, within five business days following\n the date of receipt, additional information that the independent review\n organization shall consider when conducting the external review;\n\n 2. Within one business day after the receipt of such notice, the assigned\n independent review organization shall select one or more clinical reviewers,\n as it determines is appropriate, to conduct the external review; and\n\n 3. In selecting clinical reviewers, the assigned independent review\n organization shall select physicians or other health care professionals who\n meet the minimum qualifications of § 38.2-3565 and, through clinical\n experience in the past three years, are experts in the treatment of the\n covered person’s condition and knowledgeable about the recommended or\n requested health care service or treatment. Neither the covered person, his\n authorized representative, if any, nor the health carrier shall choose or\n control the choice of the physicians or other health care professionals to be\n selected to conduct the external review.\n\nG. Within five business days after the date of receipt of the notice from the\nCommission, the health carrier or its designee utilization review entity shall\nprovide to the assigned independent review organization the documents and any\ninformation considered in making the adverse determination or the final adverse\ndetermination. Failure by the health carrier or its designee utilization review\nentity to provide the documents and information within the required time\nspecified shall not delay the conduct of the external review. If the health\ncarrier or its designee utilization review entity has failed to provide the\ndocuments and information within the required time specified, the assigned\nindependent review entity may terminate the external review and make a decision\nto reverse the adverse determination or final adverse determination. Promptly\nupon making such decision, the independent review organization shall notify the\ncovered person, his authorized representative, if any, the health carrier, and\nthe Commission.\n\nH. Each clinical reviewer selected shall review all of the information and\ndocuments timely received from the health carrier and any other information\nsubmitted in writing by the covered person or his authorized representative. The\nassigned independent review organization is not required to, but may, accept and\nconsider information submitted late from the covered person or his authorized\nrepresentative, if any. Upon receipt of any information submitted by the covered\nperson or his authorized representative, within one business day after the\nreceipt of the information, the assigned independent review organization shall\nforward the information to the health carrier.\n\nI. Upon receipt of the information from the assigned independent review\norganization, the health carrier may reconsider its adverse determination or\nfinal adverse determination. Reconsideration by the health carrier of its\nadverse determination or final adverse determination shall not delay or\nterminate the external review. The external review may be terminated only if the\nhealth carrier decides to reverse its adverse determination or final adverse\ndetermination and provide coverage or payment for the recommended or requested\nhealth care service or treatment. Promptly upon making the decision to reverse\nits adverse determination or final adverse determination, the health carrier\nshall notify the covered person, his authorized representative, if any, the\nassigned independent review organization, and the Commission in writing of its\ndecision. Upon receipt of notice of the health carrier’s decision to\nreverse its adverse determination or final adverse determination, the assigned\nindependent review organization shall terminate the external review.\n\nJ. To the extent the information or documents are available and the reviewer\nconsiders appropriate, each clinical reviewer shall also consider the following\nin reaching an opinion:\n\n 1. The covered person’s pertinent medical records;\n\n 2. The attending physician’s or health care professional’s\n recommendation;\n\n 3. Consulting reports from appropriate health care professionals and other\n documents submitted by the health carrier, covered person, his authorized\n representative, or the covered person’s treating physician or health\n care professional;\n\n 4. Whether the recommended or requested health care service or treatment is a\n covered service except for the health carrier’s determination that the\n service or treatment is experimental or investigational; and\n\n 5. Whether the recommended or requested health care service or treatment has\n been approved by the federal Food and Drug Administration, if applicable, for\n the condition, or medical or scientific evidence or evidence-based standards\n demonstrate that the expected benefits of the recommended or requested health\n care service or treatment is more likely than not to be beneficial to the\n covered person than any available standard health care service or treatment\n and the adverse risks of the recommended or requested health care service or\n treatment would not be substantially increased over those of available\n standard health care services or treatments.\n\nK. Within 20 days after being selected to conduct a standard external review,\neach clinical reviewer shall provide an opinion to the assigned independent\nreview organization on whether the recommended or requested health care service\nor treatment should be covered. Each clinical reviewer’s opinion shall be\nin writing and include the following information: a description of the covered\nperson’s medical condition; a description of the indicators relevant to\ndetermining whether there is sufficient evidence to demonstrate that the\nrecommended or requested health care service or treatment is more likely than\nnot to be more beneficial to the covered person than any available standard\nhealth care services or treatments and the adverse risks of the recommended or\nrequested health care service or treatment would not be substantially increased\nover those of available standard health care services or treatments; a\ndescription and analysis of any medical or scientific evidence considered in\nreaching the opinion; a description and analysis of any evidence-based standard;\nand information on the extent, if any, to which the reviewer’s rationale\nfor the opinion regarding the recommended or requested health care service or\ntreatment is based on (i) whether the health care service or treatment has been\napproved by the federal Food and Drug Administration for the condition or (ii)\nmedical or scientific evidence or evidence-based standards that demonstrate the\nrecommended or requested health care service or treatment is more likely than\nnot to be more beneficial to the covered person than any available standard\nhealth care service or treatment and the adverse risks of the recommended or\nrequested health care service or treatment would not be substantially increased\nover those of available standard health care services or treatments.\n\nL. Within 20 days after the date it receives an opinion from all clinical\nreviewers, the assigned independent review organization shall make a decision\nand provide written notice to the covered person, his authorized representative,\nif any, the health carrier, and the Commission. If:\n\n 1. A majority of the clinical reviewers recommend that the recommended or\n requested health care service or treatment should be covered, the independent\n review organization shall make a decision to reverse the health\n carrier’s adverse determination or final adverse determination;\n\n 2. A majority of the clinical reviewers recommend that the recommended or\n requested health care service or treatment should not be covered, the\n independent review organization shall make a decision to uphold the health\n carrier’s adverse determination or final adverse determination; or\n\n 3. The clinical reviewers are evenly split as to whether the recommended or\n requested health care service or treatment should be covered, the independent\n review organization shall obtain the opinion of an additional clinical\n reviewer. The additional clinical reviewer selected shall use the same\n information as the original clinical reviewers. The selection of the\n additional clinical reviewer shall not extend the time within which the\n assigned independent review organization is required to make a decision.\n\nM. The independent review organization shall include in the notice required\npursuant to subsection L a general description of the reason for the request for\nexternal review; the written opinion of each clinical reviewer, including the\nrecommendation of each clinical reviewer as to whether the recommended or\nrequested health care service or treatment should be covered and the rationale\nfor the reviewer’s recommendation; the date the independent review\norganization was assigned by the Commission to conduct the external review; the\ndate the external review was conducted; the date of its decision; the principal\nreason or reasons for its decision; and the rationale for its decision.\n\nN. Upon receipt of a notice of a decision reversing the adverse determination or\nfinal adverse determination, the health carrier shall promptly approve coverage\nof the recommended or requested health care service or treatment.\n\nHISTORY: 2011, c. 788.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}